Apply for Assistance

Please answer all the required questions below, denoted by a red asterisk
(*). Incomplete applications will be delayed
by efforts to verify and process the form.

Your application will be given to one of the churches that we partner
with.
You will only be contacted if your name has been selected as a potential
candidate for a vehicle.

Your application will be kept on file for 2
years. If at the end of 2 years you are still in need of a vehicle
then you will need to apply again.

Please note:
Due to our limited resources we are only able to service the greater
St. Louis area.

Contact Information

First Name:*

Last
Name:*

E-mail:

Address:*

City:*

State:*

(Missouri only)

Zip code:*

Phone number(s):*

Best time
to reach you:*

Current Vehicle Status

Do you
currently have a vehicle?*

Yes No

Is it
in good working order?*

Yes No Doesn't Apply

If not
in good working order, please explain what is wrong with your vehicle.

Church Affiliations

Are you
currently an active member of a church?*

Yes No

If "yes":

Which church?

Identification

Date of
birth:*

Month Day Year

Social
Security Number:*

Driver's
license number:*

Children

Do you
have any children?*

Yes No

If "yes":

How many
are currently residing in your household?

What are
their names and ages?

Please
list any of your children's special needs:

Personal Employment Information

Are you
employed?*

Yes No

If "yes," all fields in the section
below are required:

Employer's
name:

Address:

City:

State:

Zip code:

Phone:

Hours per
week:

Length
of employment (years, months):

Commute
(in miles):

Monthly
wages: $

Spouse's Employment Information

Is your
spouse employed:*

Yes No / I'm not married

If "yes," all fields in the section
below are required:

Spouse's
name:

Employer's
name:

Address:

City:

State:

Zip code:

Phone:

Hours per
week:

Length
of employment (years, months):

Commute
(in miles):

Monthly
wages: $

Joint Employment / Financial
Information

If you
or your spouse are not employed, what is the reason? Please provide
detailed and complete information:

What type
of assistance are you receiving, if any? Please provide detailed and
complete information:

What is
your total household monthly income? $*

Monthly Living Expenses

Please provide an approximate
amount for the following monthly expenses:

Electric:
$*

Student
loans: $*

Food: $*

Cable /
satellite TV: $*

Public
transportation: $*

Childcare:
$*

Prescriptions:
$*

Medical
expenses: $*

Natural
gas: $*

Rent /
mortgage: $*

Water /
sewer: $*

Health
insurance: $*

Auto insurance:
$*

Life insurance:
$*

Church
/ charities: $*

School
expenses: $*

Telephone:
$*

Gasoline:
$*

Trash pickup:
$*

List other
expenses: $

Additional Information

If you
wish to report any special conditions that would warrant assistances,
or if there are any additional comments you wish to make, please do
so here:

Agreement

I have honestly answered all of
the questions in this "Assistance Application" to the best of my knowledge
and understand the "Guidelines for Benevolence Assistance." I also
give permission for the appointed Wheels of Hope committee members
of this ministry to verify all of the information I have supplied
them. Additionally, I agree to provide a signature and a copy of my
driver's license upon request to a Wheels of Hope committee member.